Medication Nonadherence, Family Pressure, and Least Restrictive Care
You are an LPC in an outpatient clinic. Your client, Mr. R, age 29, has schizophrenia. He has been stable on olanzapine for two years but stopped taking it three weeks ago because he 'feels foggy' and cannot afford the copay. He lives with his mother, who calls you in a panic: Mr. R has been awake for two nights, says the neighbors are 'piping gas through the vents,' and has boarded up the kitchen window. He has no history of violence and denies suicidal or homicidal ideation. He refuses to see his psychiatrist and says 'the pills are poison.' He agrees to meet with you today at the clinic. His mother asks you to 'have him committed before he burns the building down.' There is no crisis bed available for 48 hours; mobile crisis can respond in 6 hours.
1. What risk assessment and disposition decisions should you make?
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Assess for imminent danger to self, danger to others, grave disability, and ability to care for himself. Ask directly about suicidal ideation, homicidal ideation, command hallucinations, access to weapons, and intent. His board-up behavior and fear of poisoning suggest worsening psychosis and impaired judgment, but no violence history and no stated intent mean the case is not automatically an emergency hold. Evaluate whether he can meet basic needs-food, sleep, medical care-and whether his mother can safely supervise him. Consider a less restrictive plan: same-day psychiatrist consultation, mobile crisis, medication cost assistance, safety plan, and frequent follow-up. If he is gravely disabled or imminently dangerous under State law, initiate involuntary evaluation; if not, document the criteria you considered and the safety plan. Do not promise the mother hospitalization before assessing him.
2. What confidentiality and family-involvement issues arise with Mr. R's mother?
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Mr. R is an adult, so you need his authorization before discussing his clinical care with his mother, even though she called you and lives with him. You can listen to her concerns, but do not confirm his diagnosis, medications, or appointment details without a release. Ask Mr. R whether he wants his mother involved and for what purpose; a limited release for crisis planning may be enough. If he refuses, explain that you will involve her only if there is an imminent safety emergency. Tarasoff-type duties are not triggered by his vague fear of neighbors unless there is an identifiable victim and a serious threat. If you believe he is at imminent risk of harming someone, follow State law and clinic policy. Document the mother's report, your release discussion, and any disclosure made under emergency exceptions.
3. How should you coordinate care and address the medication barrier?
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With Mr. R's release, contact the psychiatrist about the medication lapse, symptoms, and cost barrier. Explore generic olanzapine, patient assistance programs, manufacturer coupons, samples if appropriate, and insurance or pharmacy options. Ask the psychiatrist whether a different formulation or regimen is clinically appropriate; do not recommend changes yourself. Use motivational interviewing rather than confrontation: acknowledge that the foggy feeling is real, ask what would make taking medication worth it, and separate the medication decision from the delusion about poison. Involve his mother in practical support only with consent. Set a follow-up within a few days and a written crisis plan with mobile crisis and emergency numbers. Document the coordination, the plan, and what to do if symptoms worsen.